NC0059536_Permit (Issuance)_20140324

NPDES DOCUMENT SCANNING COVER SHEET
NPDES Permit:
NC0059536
Hilltop Living Center WWTP
Document Type:
Permit Issuance
Wasteload Allocation
Authorization to Construct (AtC)
Permit Modification
Complete File - Historical
Report
Speculative Limits
Instream Assessment
(67b)
Environmental
Assessment (EA)
Permit
History
Document Date:
March 24, 2014
This document is printed on reuse paper - ignore any
content on the reirerse side

AtrA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Programs
?at McCrory Thomas A. Reeder John E. Skvarla, III
Governor Director Secretary
March 24, 2014
Ms. Tisha Tuttle
Hilltop Living Center
1025 Lamb Road
Lexington, North Carolina 27295
Subject: NPDES PERMIT ISSUANCE
Permit Number NC0059536
Hilltop Living Center - Class I
Davidson County
Dear Ms. Tuttle:
Division personnel have reviewed and approved your application for renewal of the subject
permit. Accordingly, we are forwarding the attached final NPDES discharge permit. This permit is
issued pursuant to the requirements of North Carolina General Statute 143-215.1 and the Memorandum
of Agreement between North Carolina and the U.S. Environmental Protection Agency dated October 15,
2007 (or as subsequently amended).
Please note that proposed federal regulations require electronic submittal of all discharge
monitoring reports (DMRs) and specify that, if a state does not establish a system to receive such
submittals, then permittees must submit DMRs electronically to the Environmental Protection Agency
(EPA). Therefore, a requirement to begin reporting discharge monitoring data electronically using the
NC DWR's Electronic Discharge Monitoring Report (eDMR) internet application has been added to this
final permit. [See Special Condition A. (3)] For information on eDMR, registering for eDMR and
obtaining an eDMR user account, please visit the following web page:
http://portal.ncdenr.org/web/wq/admin/bog/ipu/edmr.
For information on EPA's proposed NPDES Electronic Reporting Rule, please visit the following
web site: http://www2.epa.gov/compliance/proposed-npdes-electronic-reporting-rule.
If any parts, measurement frequencies or sampling requirements contained in this permit are
unacceptable to you, you have the right to an adjudicatory hearing upon written request within thirty
(30) days following receipt of this letter. This request must be in the form of a written petition,
conforming to Chapter 150B of the North Carolina General Statutes, and filed with the Office of
Administrative Hearings (6714 Mail Service Center, Raleigh, North Carolina 27699-6714). Unless such
demand is made, this permit shall be final and binding.
Please take notice that this permit is not transferable. This permit does not affect the legal
requirements to obtain other permits which may be required by the Division of Water Resources or
permits required by the Division of Land Resources, Coastal Area Management Act, or any other
Federal or Local governmental permits which may be required.
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Location: 512 N. Salisbury St. Raleigh, North Carolina 27604
Phone: [phone] \ Fax: [phone]
Internet: www.ncwaterctualitv.orq
An Equal OpportunitylAffirmative Action Employer

Hilltop Living Center
NC0059536
Page 2
If you have any questions or need additional information, please do not hesitate to contact
Maureen Kinney of my staff at [phone].
Thomas A. Reeder
cc: Central Files
NPDES Unit Files
Winston-Salem Regional Office, Surface Water Protection Section

Permit NC0059536
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended,
Tisha Tuttle
is hereby authorized to discharge wastewater from a facility located at
Hilltop Living Center
212 Plemmons Drive
Linwood
Davidson County
to receiving waters designated as an unnamed tributary to the Yadkin River in the Yadkin -Pee Dee
River Basin in accordance with effluent limitations, monitoring requirements, and other conditions
set forth in Parts I, II, III, and IV hereof.
The permit shall become effective June 1, 2014.
This permit and the authorization to discharge shall expire at midnight on May 31, 2019.
Signed this day March 24, 2014.
mas A. Reeder, Director
'vision of Water Resources
By Authority of the Environmental Management Commission
Page 1 of 6

Permit NC0059536
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby
revoked, and as of this issuance, any previously issued permit bearing this number is no longer
effective. Therefore, the exclusive authority to operate and discharge from this facility arises under
the permit conditions, requirements, terms, and provisions included herein.
Tisha Tuttle is hereby authorized to:
1. Continue to operate an existing 0.003 MGD wastewater treatment plant, consisting of:
• two septic tanks
• flow splitter
• grease trap
• two pump tanks
• two surface sandfilters
• recirculation diversion box
• tablet chlorinator
• chlorine contact tank
• dechlorination
The facility is located at the Hilltop Living Center, 212 Plemmons Drive, Linwood, NC in
Davidson County, and
2. Discharge from said treatment works at the location specified on the attached map into an
unnamed tributary to the Yadkin River, currently classified WS-V waters in the Yadkin -Pee Dee
River Basin.
Page 2 of 6

Permit NC0059536
PART I
A. (1.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS - DRAFT
Beginning on the effective date of this permit and lasting until permit expiration, the Permittee is authorized
to discharge from Outfall 001. Such discharges shall be limited and monitored' by the Permittee as specified
below:
MONITORING REQUM IREENTS
EFFLUENT
CHARACTERISTICS
Parameter Code
LIMITS
Monthly
Average
Daily
Maximum
Measurement
Frequency
Sample
Type
Sample
Location'
Flow
50050
0.003 MGD
Weekly
Instantaneous
I or E
BOD5 —Summer*
C0310
5.0 mg/L
7.5 mg/L
2/month
Grab
E
BOD5 —Winter*
C0310
10.0 mg/L
15.0 mg/L
2/month
Grab
E
Total Suspended Solids
C0530
30.0 mg/L
45.0 mg/L
2/month
Grab
E
NH3-N —Summer*
C0610
2.0 mg/L
10.0 mg/L
2/month
Grab
E
NH3-N —Winter*
C0610
4.0 mg/L
20.0 mg/L
2/month
Grab
E
Dissolved Oxygen
00300
Daily Average > 5.0 mg/L
Weekly
Grab
E
Fecal Coliform (geometric mean)
31616
200/100 ml
400/100 ml
2/month
Grab
E
Total Residual Chlorine'
50060
17 µg/L
2/Week
Grab
E
Temperature
00010
Daily
Grab
E
Total Nitrogen (TKN + NO2 + NO3)
C0665
Quarterly
Grab
E
Total Phosphorus
C0665
•
Quarterly
Grab
E
MBAS
38260
750 µg/L
2/month
Grab
E
pH
00400
Between 6.0 and 9.0
Standard Units
2/month
Grab
E
Dissolved Oxygen
00300
Weekly
Grab
U, D
Temperature
00010
Weekly
Grab
U, D
*Summer: April 1 — October 31
*Winter: November 1 — March 31
Footnotes:
1. No later than March 1, 2015, begin submitting discharge monitoring reports electronically using NC DWR's
eDMR application system. See Special Condition A.(3.).
2. E - Effluent, I — Influent, U — Upstream approximately 50 feet above the discharge point, D — Downstream from the
discharge point approximately 300 feet from the outfall.
3. The Division shall consider all effluent TRC values reported below 50 µg/L to be in compliance with the permit.
However, the Permittee shall continue to record and submit all values reported by a North Carolina certified laboratory
(including field certified), even if these values fall below 50 µg/L.
THERE SHALL BE NO DISCHARGE OF FLOATING SOLIDS OR VISIBLE FOAM IN OTHER THAN TRACE AMOUNTS.
Page 3 of 6

Permit NC0059536
A. (2.) NUTRIENT REOPENER FOR HIGH ROCK LAKE
This permit may be reopened and modified to implement nutrient requirements in accordance with any future
TMDL and/or nutrient management strategy for High Rock Lake.
A. (3.) ELECTRONIC REPORTING OF DISCHARGE MONITORING REPORTS
Proposed federal regulations require electronic submittal of all discharge monitoring reports (DMRs) and specify
that, if a state does not establish a system to receive such submittals, then permittees must submit DMRs
electronically to the Environmental Protection Agency (EPA). The Division anticipates that these regulations
will be adopted and is beginning implementation in late 2013.
NOTE: This special condition supplements or supersedes the following sections within Part II of this permit
(Standard Conditions for NPDES Permits):
• Section B. (11.)
• Section D. (2.)
• Section D. (6.)
• Section E. (5.)
Signatory Requirements
Reporting
Records Retention
Monitoring Reports
1. Reporting [Supersedes Section D. (2.) and Section E. (5.) (a)1
Beginning no later than March 1, 2015, the permittee shall begin reporting discharge monitoring data
electronically using the NC DWR's Electronic Discharge Monitoring Report (eDMR) internet application.
Monitoring results obtained during the previous month(s) shall be summarized for each month and submitted
electronically using eDMR. The eDMR system allows permitted facilities to enter monitoring data and
submit DMRs electronically using the internet. Until such time that the state's eDMR application is
compliant with EPA's Cross -Media Electronic Reporting Regulation (CROMERR), permittees will be
required to submit all discharge monitoring data to the state electronically using eDMR and will be required
to complete the eDMR submission by printing, signing, and submitting one signed original and a copy of the
computer printed eDMR to the following address:
NC DENR / DWR / Information Processing Unit
ATTENTION: Central Files/eDMR
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
If a permittee is unable to use the eDMR system due to a demonstrated hardship or due to the facility being
physically located in an area where less than 10 percent of the households have broadband access, then a
temporary waiver from the NPDES electronic reporting requirements may be granted and discharge
monitoring data may be submitted on paper DMR forms (MR 1, 1.1, 2, 3) or alternative forms approved by
the Director. Duplicate signed copies shall be submitted to the mailing address above.
Requests for temporary waivers from the NPDES electronic reporting requirements must be submitted in
writing to the Division for written approval at least sixty (60) days prior to the date the facility would be
required under this permit to begin using eDMR. Temporary waivers shall be valid for twelve (12) months
and shall thereupon expire. At such time, D.MRs shall be submitted electronically to the Division unless the
permittee re -applies for and is granted a new temporary waiver by the Division.
Page 4 of 6

Permit NC0059536
Information on eDMR and application for a temporary waiver from the NPDES electronic reporting
requirements is found on the following web page: http://portal.ncdenr.org/web/wq/admin/bog/ipu/edmr
Regardless of the submission method, the first DMR is due on the last day of the month following the
issuance of the permit or in the case of a new facility, on the last day of the month following the
commencement of discharge.
2. Signatory Requirements [Supplements Section B. (11.) (b) and supersedes Section B. (11.) (d)1
All eDMRs submitted to the permit issuing authority shall be signed by a person described in Part II, Section
B. (11.)(a) or by a duly authorized representative of that person as described in Part II, Section B. (11.)(b). A
person, and not a position, must be delegated signatory authority for eDMR reporting purposes.
For eDMR submissions, the person signing and submitting the DMR must obtain an eDMR user account and
login credentials to access the eDMR system. For more information on North Carolina's eDMR system,
registering for eDMR and obtaining an eDMR user account, please visit the following web page:
http://portal.ncdenr.org/web/wq/admin/bog/ipu/edmr
Certification. Any person submitting an electronic DMR using the state's eDMR system shall make the
following certification [40 CFR 122.22]. NO OTHER STATEMENTS OF CERTIFICATION WILL BE
ACCEPTED:
"I cert, under penalty of law, that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and
evaluate the information submitted Based on my inquiry of the person or persons who manage the system, or
those persons directly responsible for gathering the information, the information submitted is, to the best of
my knowledge and belief true, accurate, and complete. I am aware that there are sign ficant penalties for
submitting false information, including the possibility of fines and imprisonment for knowing violations."
3. Records Retention [Supplements Section D. (6.)1
The permittee shall retain records of all Discharge Monitoring Reports, including eDMR submissions. These
records or copies shall be maintained for a period of at least 3 years from the date of the report. This period
may be extended by request of the Director at any time [40 CFR 122.41].
Page 5 of 6

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t
Tisha Tuttle
Hilltop Living Center
County: Davidson Stream Class: WS-V
Receiving Stream: UT to Yadkin River Sub -Basin: 03-07-04
Latitude: 35° 43' 39" Grid/Quad: E17NW/Salisbury (W)
Longitude: 80° 23' 0S" HUC #: 03040101
Facility
Location
(not to scale)
NPDES Permit: NC0059536

AT&
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Pat McCrory, Governor Thomas A. Reeder, Director John E. Skvarla, III, Secretary
MEMORANDUM
To:
January 30, 2014
Lisa Edwards/Eric Hudson
NC DENR / DWR / Regional Engineer
Winston-Salem Regional Office
From: Maureen Kinney
Compliance & Expedited Permitting
Subject: Review of Draft NPDES Permit NC0059536
Hilltop Living Center WWTP
Davidson County
Please indicate below your agency's position or viewpoint on the attached draft permit and return this form by
February 21, 2014. If you have any questions on the draft permit, please contact me at 919-807-6388 or
[e-mail].
ncdenr.gov.
RESPONSE: (Check one)
Signed
Concur with the issuance of this permit provided the facility is operated and maintained properly, the
stated effluent limits are met prior to discharge, and the discharge does not contravene the designated
water quality standards.
Concurs with issuance of the above permit, provided the following conditions are met:
Opposes the issuance of the above permit, based on reasons stated below, or attached:
Date: /A i/2 ©/
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 919 807-6388 (fax) 919 807-6489
VISIT US ON THE INTERNET @ HTTP://PORTAL.NCDENR.ORG/WEB/WO [e-mail]
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper

Kinney, Maureen
From: Carter, Jenifer
Sent: Monday, February 17, 2014 3:54 PM
To: Kinney, Maureen; Tisha T. Loflin; Reid, Steve; Hudson, Eric
Subject: RE: Correction: NC0059536 Hilltop
Thank you Maureen,
From my NPDES non -engineering standpoint, I see no problems with Hilltop's permit being renewed as DRAFTed.
Jenifer Carter
Before printing this email, please consider your budget and the environment.
If you must print, please print only what you need and save ink with the free Eco-Font.
NC DENR Winston-Salem Regional Office
Division of Water Resources
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Kinney, Maureen
Sent: Friday, January 31, 2014 1:27 PM
To: Tisha T. Loflin; Reid, Steve; Hudson, Eric; Carter, Jenifer
Subject: Correction: NC0059536 Hilltop
All -
Sending this file out again. Not sure how I goofed yesterday but I think I have it right this time.
Please see the attached and comment as necessary. Thank you!
Maureen
Maureen KCnney
NC DENR - DWR
NCDENR [phone]/6489 (fax)
[e-mail]
Point Source Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
United States of America
Ktpellpartalnoder'a pzitcd :
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties.
1

42008346 J000465811
AFFIDAVIT OF PUBLICATION
STATE OF NORTH CAROLINA LEXINGTON, NC February 6, 2014
DAVIDSON COUNTY
I, Lynn Bowers OF THE DISPATCH, A NEWSPAPER PUBLISHED IN THE CITY OF LEXINGTON, COUNTY AND STATE
AFORESAID, BEING DULY SWORN, SAYS THE FOREGOING LEGAL OF WHICH THE ATTACHED IS A TRUE COPY,
WAS PUBLISHED IN SAID NEWSPAPER ONCE, BEGINNING THE 6th DAY OF February, 2014.
PUBLICATION FEE: $ 101.43
(--1(il in ()C Q TC,c-/) (SEAL)
N TO AND SUBSCRIBED
MY COMMISSION EXPIRES
Ad Copy:
Public Notice
North Carolina
Environmental Management
Commission/NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Notice of Intent to Issue a
NPDES Wastewater Permit
The North Carolina
Environmental Management
Commission proposes to issue
a NPDES wastewater
discharge permit to the
person(s) listed below. Written
comments regarding the
proposed permit will be
accepted until 30 days after the
publish date of this notice. The
Director of the NC Division of
Water Resources (DWR) may
hold a public hearing should
there be a significant degree of
public interest. Please mail
comments and/or information
requests to DWR at the above
address. Interested persons
may visit the DWR at 512 N.
Salisbury Street, Raleigh, NC
to review information on file.
Additional information on
NPDES permits and this notice
may be found on our website:
http://portal.ncdenr.org/web/wp/
swp/ps/npdes/calendar or by
calling [phone]. Hilltop
Living Center requested
renewal of permit NC0059536
for the Hilltop Living Center
WWTP; Davidson County; this
EFORE ME, THIS 6 DAY OF
permitted discharge is treated
wastewater to an unnamed
tributary to the Yadkin River;
Yadkin -Pee Dee River Basin.
Town of Denton, Davidson
County, has applied to renew
NPDES permit for the Town of
Denton Water Treatment Plant
[NC0082949] discharging filter -
backwash wastewater to
Yadkin River, Yadkin -Pee Dee
River Basin.
February 6, 2014
sue'%
- - NOtafY Public
E - Davidson CounWY
MY Commission Expires
OR O� '.

FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not
require full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g.,
schools, mobile home parks, etc) that can be administratively renewed with minor changes,
but can include facilities with more complex issues (Special Conditions, 303(d) listed water,
toxicity testing, instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer/Date
Maureen Kinney 1/29/2014
Permit Number
NC0059536
Facility Name
Hilltop Living Center WWTP
Basin Name/Sub-basin number
Yadkin -Pee Dee 03-07-04
Receiving Stream
Yadkin River
Stream Classification in Permit
WS-V
Does permit need Daily Max NH3 limits?
No
Does permit need TRC limits/language?
Yes No
Does permit have toxicity testing?
Yes No
Does permit have Special Conditions?
Yes No — E-Reporting Requirement/Re-opener
Yes No — Temperature & D.O.
Does permit have instream monitoring?
Is the stream impaired (on 303(d) list)? For
what parameter?
Yes No
Any obvious compliance concerns?
No
Any permit mods since last permit?
No
Current expiration date
5/31/14
New expiration date
5/31/19
Comments received on Draft Permit?
Renewal application was not received until 1/23/14, so the draft was late to public notice.
Please note the following modifications to this draft:
• Parameter codes have been added to Section A.(1.) Effluent Limitations and
Monitoring Requirements.
• A Nutrient Re -opener has been added to all dischargers in sub -basins 03-07-01
thru 03-07-07, see Special Condition A. (2.).
• A requirement to begin reporting discharge monitoring data electronically using
the NC DWR's Electronic Discharge Monitoring Report (eDMR) internet
application has been added to this draft. [See Special Condition A. (3.)] For
information on eDMR, registering for eDMR and obtaining an eDMR user
account, please visit the following web page:
http ://portal.ncdenr. ora/web/wq/admin/bog/ipu/edmr.

14-01-03 14:41 F ROM- NC DENR - YISR02 336-771-4632
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic waste
Mail the complete application to:
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mall Service Center, Raleigh, NC 27699-1617
NPDES Permit
`NC00 q s mai
T-483 P0002/0004 F-865
this form in computer use the TAB key or the up - down ' • ws o move from one
If you are completing f Iease print or type.
field to the next. To check the boxes, click your mouse on top of the box Otherwise, p
LSi
tr\c rznier-
1\ 1 `0 \1 Cect+ez-
cb4s- . V_,a_tNeA, 6 itocLol
1. Contact Information:
Owner Name
Facility Name
Mailing Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
P.X`I -1-AN .2 L
Ck e; -.7 c ,
{31(d g S3 - `"7 Clfti () e,x • L�
p+crv-- r\t-f
Location of facility producing discharge: N i et p c164-e ci"` �
2. - 1 G
$
Check here if same address as above 0
Street Address or State Road \ P\ e-`M 0 n- �'Z
City
State / Zip Code
County
f\ 1Z0t7 r3
3. Operator Information:
operates the facility. (Note that this is not
Name of the firm, public organization or other entity that o p
referring to the Operator in Responsible Charge or ORC)
Name LtAkkor Leo no pot
Mailing Address c Z pUd j.,s :la_ a_ tar..
City 1--c • +� ,
State / Zip Code /A` �, C. 2'7 �A j
Telephone Number (33�) 4,3 q - b qa.,
Fax Number { )
e-mail Address /c / / u /e lj tj a k', z O,fl
Form-011112
1 of 3

14-01-03 14:41 FROM- NC DENR - 1iSR02 336-771-4632 T-483 PO003/0004 F-865
NPDES' APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply):
Industrial ❑ Number of Employees
Commercial 0 Number of Employees
Residential ❑ Number of Homes
School ❑ Number of Students/Staff
Other [� Explain: N,14* C,aSt Opme, to p, 3z
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.): 0 © % iqs_iczt 6 1, % 0 *C' k A f ? O
Number of persons served: Z O
5. Type of collection system
El Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. O utfall Information:
Number of separate discharge points 1
Outfall Identification number(s) NISN
Is the outfall equipped with a diffuser? ❑ Yes [r No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfall):
12.
•
8. Frequency of Discharge: Er Continuous
If intermittent:
Days per week discharge occurs:
❑ Intermittent
Duration:
9. Describe the treatment system
List all installed components, including capacities, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
2 of 3
-{-wo Su"-C.4c . p-1
etzu
- jo
c_ i, t Y-;' Cam,. - * k-
Form-D 11112

• 114-01-03 14:42 FROM- NC DENR - VSRO2 336-771-4632
NPDES APPLICATION - FORM D wastewaters <1.0 MGD
For privately -owned treatment systems treating 100% domestic
T-483 tiuuo+f uuu,
10. Flow Information:
Treatment Plant Design flow 0 • ab) MGD 3 years)
Annual Average daily flow • o , ?4 MGD (for the previous
Maximum daily flow = ©a 2 r ? MGD (for the previous 3 years)
11. Is this facility located on I dian country?
❑ Yes
al No
12. Effluent Data Temperature and pH shall be grab
ammeters listed. Fecal Coliform, sis is reported,
NEW APPLICANTS: fo all other
Provide data for thue P composite sampling shall be used. If more than one analy
samples, for all other parameters 24-hour comp � one analysis is reported, report as daily ��Av�-pge over
and monthly id average. If y Unit Maximum) and Monthly
report daily maximum' hest single reading (Daily RENEWAL APPLICANTS: Provide the highest vn�ts of
ameters current! in our • ermit. Mark other • arameters "N/A .
the ast 36 months or af' Da31y Monthly Mean
13. List all permits, construction approvals and/or applications:
TYPe
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
14• APPLICANT CERTIFICATION application and that to the
that I am familiar with the informationcontained
true, and accurate.
I certify
best of m knowledge and belief such information
S
Printed name of 'erson Signing
Permit Number Type
NESHAPS (CAA)
Ocean Dumping (MPRSA)
isiu��5=� , Dredge or fill (Section 404 or CWA)
Other
Title
3-) -1,1
Date
Signature of Applicant
states: Anyperson who knowingly makes any false statement representation, or certification in any
application,
p li Carolina General,report,
rt plan, 1 or other document6 (b)or re ired to be maintained under Article 21 or regulation�sri f t e E Jiro m a ce o method
a ommissio record, report, r cte, rworalfiles Q rs with, or knowingly renders Inaccurate any recording
oranagement
regulations of the Environmental Management Commission implementing that Article, shall be
Commission Implementing mat Article, under A falsifies, ramps 1g U.S.C. Article,
sh shall
be
required to be operated orp maintained Article 21 e9 or beds for a similar offense.)
01
punishable bya fine not to exceed $25,000, or by imprisonment not exceed � months, or by both.
provides
e a punishment
nor pufy
Provides a punishment by a fine of not more than $25,�Q or imprisonment not more than years,
Permit Number
res,
3of3
Form-D 11112

Hilltop Living Center - NC0059536
USGS Quad Name: E17NW Salisbury
Receiving Stream: UT to Yadkin River
Stream Class: WS-V
Subbasin: Yadkin -Pee Dee - 030704
Lat.: 35°43'39"
Long.: 80°23'05"
tFacili
Locat
\forthl
Davidson County